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Titone F, Restaino S, Moretti E, Vullo G, Poli A, Arcieri M, Paglietti C, Tonetto F, Parisi G, Barbui E, Trovò M, Scambia G, Driul L, Vizzielli G. Fiducial markers in adjuvant setting for a patient affected by endometrial cancer: a case report. Front Oncol 2023; 13:1174675. [PMID: 37711202 PMCID: PMC10498116 DOI: 10.3389/fonc.2023.1174675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Intermediate-high and high-risk endometrial cancer often require adjuvant treatments such as radiotherapy (RT) or brachitherapy (BT) to reduce the risk of loco-regional relapse. Inter- and intra-fraction variability of internal pelvic anatomy are possibly the largest source of error affecting pelvic RT. The implantation of Fiducial Makers (FMs) in the vaginal cuff of patients receiving RT or BT could help patient daily setup, image guidance and intra-fraction detection of the radiation targets. Clinical case We have evaluated the case of an 80-year-old woman treated with surgery for endometrioid adenocarcinoma G2 (stage pT1b Nx LVSI+) who underwent adjuvant pelvic IMRT after the implantation of vaginal cuff FMs. CT-simulation Treatment Planning and IGRT strategy Patient underwent planning CT scan 10 days after FMs implantation. RT consisted of 45Gy in 25 daily fractions to pelvic lymph nodes and surgical bed with simultaneous integrated boost up to 52.5Gy to the vaginal cuff and the upper two-thirds of the vagina. Cone beam Computed Tomography (CBCT) was acquired prior to every RT fraction for IGRT. Bladder and rectum were re-contoured on every CBCTs. Bladder and rectal volumes and median shifts were reported on a prospective database to quantify the impact of the pelvic organ variations. Results The patient reported no discomfort during the FMs implantation, and no complications were seen. No evidence of FMs migration was reported. Bladder and rectal volumes planned contours were 245 and 55.3cc. Median bladder volumes for approved and "not acceptable" CBCTs were 222cc (range: 130-398) and 131cc (range: 65-326), respectively. Median rectal volumes for approved and "not acceptable" CBCTs were 75cc (range: 58-117) and 90cc (range: 54-189), respectively. The median values of the anterior-posterior, superior-inferior, lateral direction shifts were 3.4, 1.8 and 2.11 mm, respectively. Conclusion In our clinical case, the implantation of FMs in the vaginal cuff of a patient who underwent pelvic adjuvant RT was well tolerated and reported no complications. The use of IGRT procedures based on FMs surrogating the vaginal vault may reduce inter-observer variability and pave the way for adaptive strategies or stereotactic treatments as external beam pelvic boost in gynecological field.
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Affiliation(s)
- Francesca Titone
- Radiation Oncology Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Eugenia Moretti
- Medical Physics Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Gianluca Vullo
- Radiation Oncology Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Alice Poli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Martina Arcieri
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy
| | - Chiara Paglietti
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Fabrizio Tonetto
- Radiation Oncology Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Giuseppe Parisi
- Radiation Oncology Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Elisa Barbui
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Marco Trovò
- Radiation Oncology Unit, Department of Oncology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Giovanni Scambia
- Dipartimento per le Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, Unità Operativa Complessa (UOC) Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a carattere Scientifico (IRCCS), Rome, Italy
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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Impact of a fiducial marker based ART strategy on margins in postoperative IMRT of gynecological tumors. Radiother Oncol 2021; 158:1-6. [PMID: 33587973 DOI: 10.1016/j.radonc.2021.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/24/2020] [Accepted: 01/29/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate the potential of an offline Adaptive Radiotherapy (ART) strategy, based on the interfractional vagina motion (IVM) measured using fiducial markers (FM) during an initial number of fractions, on the CTV to PTV margins in post-operative gynecological patients. MATERIALS AND METHODS In 18 patients, treated post-operatively for gynecological tumors, the systematic residual IVM was quantified after simulating an offline ART procedure, utilizing the average IVM measured with FM for a varying initial numbers of fractions to find the optimal moment to adapt the treatment plan and a threshold for selecting patients for replanning. Clinical margins for a zero, 2 and 5 mm threshold based strategy were calculated to assess the possible margin reduction. RESULTS Applying an ART strategy based on the average IVM of the initial 5 fractions reduces the systematic IVM significantly (P < 0.025), allowing a reduction of the clinical margin of 3 mm (20%) in the CC direction and 2 mm (13%) in the AP direction. A 2 mm threshold for selecting patients for replanning shows no difference in the reduction of the clinical margin, but reduces the workload with 12%. CONCLUSION An ART strategy based on adapting on the average IVM during the initial 5 fractions of treatment provides an opportunity to reduce the CTV to PTV margins in postoperative gynecological tumors. To keep the workload in balance with the best achievable margin reduction, a threshold for selecting patients for plan adaptation is recommended.
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Barsky AR, Kim MM, Dreyfuss A, Dong L, Metz JM, Anamalayil S, Li T, Taunk NK. Initial Clinical Experience Treating Patients With Gynecologic Cancers on a 6MV Flattening Filter Free O-Ring Linear Accelerator. Adv Radiat Oncol 2020; 5:920-928. [PMID: 33083654 PMCID: PMC7557142 DOI: 10.1016/j.adro.2020.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/26/2020] [Accepted: 01/26/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Radiation therapy (RT) is commonly used in the treatment of gynecologic cancers. Intensity-modulated RT (IMRT) has been shown to reduce gastrointestinal toxicity compared with 2-dimensional and 3-dimensional RT modalities. We report the initial clinical experience using IMRT for gynecologic cancers with a novel 6MV flattening filter free O-ring linear accelerator (6X-FFF ORL). METHODS AND MATERIALS We retrospectively identified consecutive women with uterine or cervical cancer who received pelvic RT on Halcyon (Varian Medical Systems, Palo Alto, CA), a novel 6X-FFF ORL. We report their clinicopathologic data, RT details, early disease-control outcomes, acute toxicities, dose-volume histogram data, couch corrections, and treatment times. RESULTS Seventeen women received RT on a 6X-FFF ORL for uterine cancer (76%) or cervical cancer (24%) between January 2017 and September 2019. RT was delivered postoperatively (82%) or to intact disease (18%), to a median dose of 50.4 Gy (range, 19.8-55.0 Gy) in 25 fractions (range, 11-28), with 12% receiving extended-field RT and 65% receiving chemotherapy. Target and organ-at-risk constraints were met in all plans. The 3-dimensional vector couch correction average was 0.90 ± 0.37 cm. The mean beam-on time was 2.9 ± 0.4 min and mean treatment time, from imaging start to beam-off, was 3.6 ± 0.4 min. Grade 2 fatigue, anorexia, diarrhea, bloating, and nausea occurred in 41%, 12%, 12%, 6%, and 6% of patients, respectively. There were no grade ≥3 toxicities. CONCLUSIONS In the initial clinical report of pelvic RT for gynecologic cancers using a 6X-FFF ORL, the linac showed versatility in treatment; comparability to flattening-filtered IMRT for early disease-control, toxicity, and dosimetry; and treatment speed that compared favorably to IMRT on a C-arm gantry. Accordingly, a 6X-FFF ORL may increase throughput or reduce day length in departments with high gynecologic cancer volumes, without compromising clinical outcomes.
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Affiliation(s)
- Andrew R Barsky
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Michele M Kim
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Lei Dong
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - James M Metz
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Shibu Anamalayil
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Taoran Li
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Neil K Taunk
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
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Murrell DH, Warner A, Benwell Q, Wells W, Scott D, Velker V, Hajdok G, D’Souza DP. Image-guided radiation therapy for post-operative gynaecologic cancer: patient set up verification with and without implanted fiducial markers. Acta Oncol 2018; 57:1346-1351. [PMID: 29774779 DOI: 10.1080/0284186x.2018.1473638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Intensity modulated radiotherapy (IMRT) is increasingly being used to treat gynaecological malignancies in the postoperative setting. The purpose of this study was to evaluate the use of image-guided radiotherapy (IGRT) using cone-beam computed tomography (CBCT) with fiducial markers for daily localization. MATERIAL AND METHODS A single institution study was performed of consecutive cervical or endometrial cancer patients receiving adjuvant external beam radiotherapy (n = 15). Patients were set up at treatment using daily CBCT and alignment of implanted fiducial markers. Image registration was retrospectively completed based on soft tissue matching and the resulting couch shifts from each IGRT method were compared (n = 122). RESULTS The median shift between IGRT methods was 2 mm, 1 mm and 1 mm in the anterior-posterior (A-P), superior-inferior (S-I), and lateral directions, respectively. The largest deviations were observed in the A-P direction; however, more than 90% were within 5 mm and 63.9% were within 2.5 mm. CONCLUSIONS IGRT based on soft tissue match provides a noninvasive convenient method for daily localization and is accurate within treatment uncertainty for the majority of cases.
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Affiliation(s)
- Donna H. Murrell
- Department of Physics and Engineering, London Regional Cancer Program, London, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Quinn Benwell
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Wendy Wells
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Danielle Scott
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Vikram Velker
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - George Hajdok
- Department of Physics and Engineering, London Regional Cancer Program, London, Ontario, Canada
| | - David P. D’Souza
- Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
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Li BS, Shi H, Wen M, Xiao MY, Wang J. Widespread lymph node recurrence of major duodenal papilla cancer following pancreaticoduodenectomy. World J Gastroenterol 2015; 21:13593-13598. [PMID: 26730173 PMCID: PMC4690191 DOI: 10.3748/wjg.v21.i48.13593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 11/06/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
Major duodenal papilla cancer (MDPC) represents the primary type of duodenal cancer, and is typically considered a periampullary carcinoma as most tumors arise in this region. This report describes an extremely rare case involving a patient with rapidly and extensively recurrent MDPC following pancreaticoduodenectomy, who achieved complete response by concurrent image-guided radiation and intravenous oxaliplatin plus oral capecitabine therapies. The patient was a 50-year-old female who was admitted to our hospital 6 wk after resection for MDPC for evaluation of a nontender and enlarged node in the left side of her neck. After clinical work-up, the patient was diagnosed with postoperatively recurrent MDPC with widespread lymph node metastases at the bilateral cervix, mediastinum, abdominal cavity, and retroperitoneal area. She was administered whole field image-guided radiation therapy along with four cycles of the intravenous oxaliplatin plus oral capecitabine regimen. A complete response by positron emission tomography with 18-fluorodeoxyglucose was observed 4 months after treatment. The patient continues to be disease-free 2 years after the diagnosis of recurrence.
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